Cardiac Arrest Care in Resource-Limited Settings.

The contributors to this statement were selected to ensure expertise in all the disciplines relevant to post–cardiac arrest care. In an attempt to make this document universally applicable and generalizable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post–cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations took place initially by e-mail, followed a series of telephone conferences and face-to-face meetings of the cochairs and writing group members. International writing teams were formed to generate the content of each section, which corresponded to the major subheadings of the final document. Two team leaders from different countries led each writing team. Individual contributors were assigned by the writing group cochairs to work on 1 or more writing teams, which generally reflected their areas of expertise. Relevant articles were identified with PubMed, EMBASE, and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Drafts of each section were written and agreed on by the writing team authors and then sent to the cochairs for editing and amalgamation into a single document. The first draft of the complete document was circulated among writing team leaders for initial comment and editing. A revised version of the document was circulated among all contributors, and consensus was achieved before submission of the final version for independent peer review and approval for publication. This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimization of post–cardiac arrest care and to pinpoint the need for research focused on gaps in knowledge that would potentially improve outcomes …

Patients hospitalized for severe coronavirus disease 2019 (COVID-19) infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared with a pre-COVID-19 period. All patients who experienced an IHCA at our hospital from March 1, 2020 through May 15, 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1, 2019 to December 31, 2019 were identified. All patient data were extracted from our hospital's Get With The Guidelines-Resuscitation registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions, and overall outcomes of IHCAs during the COVID-19 pandemic were compared with IHCAs in 2019, before the COVID-19 pandemic. There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared with 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% versus 33%; 19% versus 60% in 2019; P<0.001), were overall shorter in duration (median time of 11 minutes [8.5-26.5] versus 15 minutes [7.0-20.0], P=0.001), led to fewer endotracheal intubations (52% versus 85%, P<0.001), and had overall worse survival rates (3% versus 13%; P=0.007) compared with IHCAs before the COVID-19 pandemic. Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared with those who had an IHCA before the COVID-19 pandemic. Our findings highlight important differences between these 2 time periods. Further study is needed on cardiac arrest care in patients with COVID-19.

Of late there has been a debate on whether green revolution has reduced absolute poverty among farm families in India. Most of the studies examining the issue relate to the all-India rural sector. But since the green revolution has not spread evenly in all the regions, the changes in the level of poverty reported in these istudies do not strictly relate to the phenomenon. Haryana is one of those few regions where new agricultural technology has spread more widely than others and therefore the experience of its farmers should provide us a better picture of how poverty among farmers changes with the spread of new farming technology.

Higher socioeconomic status is associated with lower in-hospital cardiac arrest: How can we address this socioeconomic inequality?

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

In the new (2010) cardiopulmonary resuscitation (CPR) guidelines, and for adult vic-tims of out-of-hospital cardiac arrest, the four pillars of resuscitation are the immedi-ate recognition of cardiac arrest and activation of the emergency response system, early performance of high quality bystander CPR simplified to include chest com-pressions alone ( cardiocerebral resuscitation-CCR , which seems comparable to con-ventional CPR) and early defibrillation. To effect the latter, integration of automatic external defibrillators (AEDs) into a system of emergency care is critical in the Chain of Survival in public places outside the hospitals. Organized post– cardiac arrest care is the new fifth link in the chain of survival, with an emphasis on multidisciplinary programs that focus on optimizing hemodynamic, neurologic, and metabolic func-tion, including therapeutic hypothermia and early primary percutaneous intervention in cardiac arrest victims suffering from an acute myocardial infarction, which may improve survival to hospital discharge for those who achieve recovery of spontaneous circulation following cardiac arrest.

ObjectivesThe objectives of this project were to collect and analyze clinical governance documents related to family-centred care and cardiac arrest care in Canadian EMS organizations; and to improve the family-centredness of out-of-hospital cardiac arrest care through experience-based co-design.MethodsWe conducted qualitative document analysis of Canadian EMS clinical governance documents related to family-centred and cardiac arrest care, combining elements of content and thematic analysis methods. We then used experience-based co-design to develop a family-centred out-of-hospital cardiac arrest care policy and procedure template.ResultsThirty-five Canadian EMS organizations responded to our requests, representing service area coverage for 80% of the Canadian population. Twenty documents were obtained for review and six overarching themes were identified: addressing family in event of in-home death, importance of family, family member escort, provider discretion and family presence discouraged. Informed by our qualitative analysis we then co-designed a policy and procedure template was created that prioritizes patient care while promotes family-centredness.ConclusionsThere were few directives to support family-centred care by Canadian EMS organizations. A family-centred out-of-hospital cardiac arrest care policy and procedure template was developed using experience-based co-design to assist EMS organizations improve the family-centredness of out-of-hospital cardiac arrest care.

resuscitation ◼ defibrillators ◼ delivery of health care ◼ echocardiography ◼ electric countershock ◼ epinephrine ◼ extracorporeal membrane oxygenation ◼ heart arrest ◼ infusions, intraosseous ◼ intubation, intratracheal

The surging COVID-19 pandemic has raised ethical and moral dilemmas that Western nations with first-rate medical care facilities rarely confront-how to best allocate standard life-saving medical resources when escalating demand outstrips supply. Sadly, these quandaries are familiar challenges in resource-poor countries. What makes this pandemic notable is that the scope and number of reported cases have been primarily in First World nations, raising questions in some settings about the use of emergency treatments like resuscitation care for in-hospital cardiac arrest (IHCA). This perspective reviews the debate around these ethical and moral dilemmas more broadly but focuses specifically on IHCA and the response of the medical community.

Background: As cardiac arrest remains an event associated with high morbidity and mortality, interventions to mitigate neurologic injury and improve survival in these patients is an area of ongoing research. As carbon dioxide levels play an important role in cerebral vascular regulation, targeting a specific partial pressure of carbon dioxide (PaCo2) is a potential therapeutic intervention in cardiac arrest care. Our study aims to determine the impact of PaCo2 on survival and neurologic outcomes in in-hospital cardiac arrest (IHCA) patients. Methods: This study is a single center prospective observational study. The population included IHCA patients from August 2011 to July 2021. Arterial blood gas data (ABG) was available for 154 patients intra cardiac arrest and 336 patients in the post ROSC period. PaCo2 levels from the ABG data where subdivided into different ranges including hypocapnia (PaCo2 &lt;35mm Hg), normocapnia (35-45 mm Hg) and hypercapnia (&gt;45mmHg). The primary outcomes of interest were survival to hospital discharge and neurologic outcome. Results: Analysis of the PaCo2 data demonstrated that intra arrest PaCo2 was not associated with survival to discharge (p value 0.129). Mild hypercapnia (PaCO2 46-54 mmHg) and moderate hypercapnia (55-79mmHg) intra arrest were associated with favorable neurologic outcomes (p value 0.039). A univariate analysis of post ROSC ABG data demonstrated that normocapnia was associated with survival to discharge (p value &lt;0.001) and favorable neurologic outcomes (p value 0.05). Similar findings were seen in two multivariate analyses examining the association of PaCo2 with survival and neurologic outcome. The multivariate analysis examining survival showed that hypocapnia and hypercapnia were associated with a higher mortality compared to normocapnia (p values 0.016 and &lt;0.001). In the multivariate analysis examining neurologic outcomes, hypercapnia was associated with worse neurologic outcome when compared to normocapnia (p value 0.004). Conclusions: Post ROSC, normocapnia was associated with favorable neurologic outcomes and survival to discharge. Our study supports targeting normocapnia in the post cardiac arrest period.

IntroductionCardiac arrest is characterized depending on location as in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). Strategies for Post Cardiac Arrest Care were developed based on evidence from OHCA. The aim of this study was to compare characteristics and outcomes in patients admitted to intensive care after IHCA and OHCA. MethodsA retrospective multicenter observational study of adult survivors of cardiac arrest admitted to intensive care in southern Sweden between 2014–2018. Data was collected from registries and medical notes. The primary outcome was neurological outcome according to the Cerebral Performance Category (CPC) scale at 2–6 months. Results799 patients were included, 245 IHCA and 554 OHCA. IHCA patients were older, less frequently male and less frequently without comorbidity. In IHCA the first recorded rhythm was more often non-shockable, all delay-times (ROSC, no-flow, low-flow, time to advanced life support) were shorter and a cardiac cause of the arrest was less common. Good long-term neurological outcome was more common after IHCA than OHCA. In multivariable analysis, witnessed arrest, age, shorter arrest duration (no-flow and low-flow times), low lactate, shockable rhythm, and a cardiac cause were all independent predictors of good long-term neurological outcome whereas location of arrest (IHCA vs OHCA) was not. ConclusionIn patients admitted to intensive care after cardiac arrest, patients who suffered IHCA vs OHCA differed in demographics, co-morbidities, cardiac arrest characteristics and outcomes. In multivariable analyses, cardiac arrest characteristics were independent predictors of outcome, whereas location of arrest (IHCA vs OHCA) was not.

As with other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), Part 5 is based on the International Liaison Committee on Resuscitation (ILCOR) 2015 international evidence review process. ILCOR Basic Life Support (BLS) Task Force members identified and prioritized topics and questions with the newest or most controversial evidence, or those that were thought to be most important for resuscitation. This 2015 Guidelines Update is based on the systematic reviews and recommendations of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations , “Part 3: Adult Basic Life Support and Automated External Defibrillation.”1,2 In the online version of this document, live links are provided so the reader can connect directly to the systematic reviews on the ILCOR Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, BLS 740). We encourage readers to use the links and review the evidence and appendix. As with all AHA Guidelines, each 2015 recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE). The 2015 Guidelines Update uses the newest AHA COR and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as well as LOE C-LD (based on limited data) and LOE C-EO (consensus of expert opinion). The AHA process for identification and management of potential conflicts of interest was used, and potential conflicts for writing group members are listed at the end of each Part of the 2015 Guidelines Update. For additional information about the systematic review process or management of potential conflicts of interest, see “Part 2: Evidence Evaluation and Management of Conflicts of Interest” in this …

Objective: A descriptive analysis of NIH funding of the top science gaps recognized in the 2015 AHA Emergency Cardiac Care cardiac arrest (CA) guidelines over a five-year period. Methods: A search within NIH RePORTER for the period of 2015 to 2019 was performed using the following terms: “cardiac arrest” or “cardiopulmonary resuscitation” or “heart arrest” or “circulatory arrest” or “pulseless electrical activity” or “ventricular fibrillation” or “resuscitation”. Grants were identified as CA research (yes/no) using predefined, published criteria. NIH funded CA abstracts were individually reviewed and categorized using the previously recognized ten most urgent science gaps in the 2015 AHA ECC CA guidelines published by Panchal et al. The data were analyzed descriptively. Results: The search yielded 1,518 NIH-funded grants over the study period, of which 172 (11.3%) were classified as individual CA grants. A total of 42 (24.4%) did not address a top 10 scientific gap. The remaining 130 grants addressed the following scientific gaps: optimization of post-CA care (78 grants, 45.3%), prediction of patients at risk of CA (12, 7%), developing tools for early neuroprognostication (7, 4.1%), hemodynamic monitoring/goal directed resuscitation (4, 2.3%), optimizing educational strategies for providers (4, 2.3%), optimal airway strategies (2, 1.2%), and understanding why bystanders fail to respond (1, 0.6%). Previously existing scientific networks or data centers accounted for 19 (11%) grants and 3 (1.7%) grants addressed both optimizing post-CA care and early neuroprognostication gaps. Recognized scientific gaps in dispatch-directed CPR, individualized resuscitation strategies, and novel technology for out-of-hospital CA identification and response did not receive specifically directed NIH grant funding. Conclusion: Additional research funding targeting critical knowledge gaps in the 2015 cardiac arrest guidelines is needed promote broader evidence-based guideline development. Current NIH funding is concentrated in a few areas leaving disparity among recognized high-yield scientific gaps in CA care.

Epidemiology of Cardiogenic Shock in Hospitalized Adults With COVID-19: A Report From the American Heart Association COVID-19 Cardiovascular Disease Registry.

Despite several advances in resuscitation care over the last decade, in-hospital cardiac arrest (IHCA) remains common and is linked to poor survival. Approximately 200 000 hospitalized patients suffer IHCA and undergo cardiopulmonary resuscitation in the United States annually, with fewer than 20%